I was riding the train home with John Santa, director of health ratings at Consumer Reports, on the night of Sunday 10 November. I asked him for an example of how conflict of interest happens with doctors. He prefaced his story by explaining the premise that there is something about human nature which causes unavoidable bias manifesting as excessively favorable sympathetic behavior whenever one person receives any gesture of good will from another, with a hugely increased bias when that goodwill takes the form of anything which has any material value. Dr. Santa said that sociological studies exist which demonstrate that even the receipt of a gift of low value makes the receiver biased to the giver, so for example, if one person accepts a pen from another then the receiver’s entire thought process becomes suspect to the illogical influence of having received a gift. I wanted to know more about those studies but I will follow up on that when I have time; I accepted the premise in any case.

Dr. Santa explained that in his past he was in a profesional collective of doctors who managed policy in medical centers and schools, and that his collective was interested in geriatrics. Dr. Santa said that he was to stay abreast of developments in this field, and that he was to develop and teach best practices to about 150 others, and that each of these 150 others interacted with perhaps 10 others themselves, so what he suggested was likely to influence 1500 people rather directly and even more as those 1500 went on with their careers with the seeds of his suggestions planted within them. He explained this as a casual and common occurrence – it simply is not practical for all doctors to stay current on all aspects of medicine, so some community leaders with particular interests and community esteem tend to follow their specialties closely then share the salient points with their colleagues and be available to consult on request. In his social organization for geriatrics, Dr. Santa would talk with his peers who also had uncommon interest in this topic, and they would go to the important conferences and discuss papers with each other and otherwise share professional specialty camaraderie.

With Dr. Santa being in a managerial role in various departments of his hospital and at a medical school, it was appropriate in the context of medical and research culture that when opportunities appeared for him to request funding then he should do so. Everyone expects the government to fund certain things, and various non-profit foundations fund things. One day he got a call from a pharmaceutical company who wanted to visit the medical center to organize a lecture series on treating patients with dementia. Dr. Santa talked with their representative a few times to understand what it is that they wanted to do, and he talked it over with his colleagues also. The proposal was that the pharmaceutical company would send a series of undisputed experts in the field to give presentations, and Dr. Santa was to arrange for an audience and host them. He agreed to this, and after agreeing to it, the company added that they would give the medical program which hosted them a USD 10,000 grant in addition to funding the lecture series. The grant could be used for anything the organization liked to support geriatrics. In sales culture, there is a maxim which says, “Do not sell what is already sold.” This refers to a salesperson giving a pitch to sell a customer something, to which the customer agrees. Traditional sales practice is to cease the sales pitch at this point, because if the customer thinks into the matter further then there is a chance that the customer will cancel the sale, whereas if the customer does not continue to reflect on the sale then the default result would be the completion of the sale. Dr. Santa described to me how the offering of the grant was strange social behavior because it was not part of the negotiation process, but rather something which came after negotiation. Also, offering money in this way would not be a seemly part of deciding what kinds of lectures professional people should hear, because it is inappropriate to pay for medical professionals’ time. Offering the money after seems like icing on a cake – an extraneous sweet thing to an already agreeable sweet situation.

The lecture series proceeded and it was exemplary and without any obvious bias. Talk of dementia was an expected part of the lecture series as this is an affliction of old age. It so happened that the company funding this series had just released a new dementia drug which they developed, and there was a presumption that they wanted doctors to prescribe their new drug. However, the doctors are not to be fooled and the presenters themselves were not seemingly shills for the pharmaceutical company or salespeople; they really were leaders in the field of geriatrics, excellent presenters, and thoughtful doctors. In their talks they gave no special favoritism to the company’s new drug, nor was the drug particularly profiled except as one of the drug options among many others on the market, and drug options were just one option of many treatments. As is common in contemporary United States culture, at the end of lectures which discussed drugs there were free samples available of drugs manufactured by the company sponsoring the event. Doctors could take these samples and give them to their patients, if they liked. People attending these lectures may not realize who is sponsoring the lectures, and certainly the content in the lecture would not indicate this. Is there harm in such a lecture series? The doctors who attend are getting good information with no obvious bias, and the presenters have no special obligation to promote any company’s products. The pharmaceutical company’s representatives were on hand to answer questions if anyone liked.

After this event Dr. Santa was invited to a conference hosted by the pharmaceutical company. The conference was for specialists who worked in geriatrics and who were leaders in the field. Dr. Santa was invited to come, but then also he is continually invited to conferences and could go to a medical conference every week if he liked. There simply are too many conferences for anyone to attend them all. What was a bit unusual about this conference was that invitees were welcome to bring their families, and that the conference was at a luxury ski resort in Vale, Colorado. It is stressful being a doctor for sure, and doctors need to relax to be able to do their jobs. If a doctor is not relaxed and happy then the doctor will definitely have more accidents and harm patients unintentionally, so doctors should take breaks. Doctors need to have a happy family life, because again if a doctor does not find peace at home then the doctor will have stress and then do bad work with patients. Going to conferences is hard work – scientists at conferences present complicated research and even if the material is interesting the intensity of the learning experience is stressful in itself. Should a doctor use his or her free time to go to a professional conference and be intensely educated for 8-12 hours, taking away time from work and family to do so? What other professions need to spend so much time in continuing education as doctors? Why should doctors follow so much current research? Who has time for this, and who can take time off work for this?

It seems like it would be nice if instead of leaving one’s family, a doctor could take his or her family to the conference. In this way the doctor is less stressed about the travel, plus is not alone in the hotel, so the conference can become a fun family event rather than only intense education. Would it not be better for the conference to be in a comfortable place, rather than a utilitarian learning institution? It the doctors are more comfortable then they would be in a relaxed mood to learn more and feel better about the experience. At this conference in Vale, Dr. Santa and his wife were greeted at the luxury hotel with nice new jackets to keep warm. They were offered tabs to do whatever they liked, and for example, while Dr. Santa was in training his wife could take free skiing lessons all day. What else should she do? Surely she should not just be alone after the disruptive experience of leaving her home to go to some strange conference. At the end of the day Dr. Santa would be happy about having learned something and be able to know that his wife was well-cared for having the fun experience of learning to ski. The hotel and city had other tourist perks and anything they liked was theirs.

All of this seemed like an odd situation. I understand how stressful attending conferences is. I love conferences but it is a personal sacrifice to me, and I can imagine people who are so in demand that conferences would actually want them to attend and for wanted people to actually need to turn down most offers just because it is beyond their work capacity to attend them all. Why should such people not only attend comfortable conferences?

Suppose that a company develops a new drug for dementia, and it is called drug X. Suppose that it is similar to any other drug on the market, and that it costs some similar price like $100 a month and would be taken long term if a person had dementia. Lots of drugs are ordinary in this way for the condition they treat. John Santa is something of a leader, if the field has leaders. Actually a conference hall could be filled with people in a similar position as he, because so much of medicine is decided locally or regionally. I already mentioned the structure of Dr. Santa’s hierarchy; he provides advice to about 150 other doctors only in his field, then those doctors each teach students or general practitioners or any other doctor who does not have any geriatrics special training. Suppose that John Santa were to say, “All of the drugs are good and mostly the same, but I often try to prescribe drug X first.” Suppose that each doctor sees 10 patients a month – 150 direct connections x 10 secondary connections x 10 patients each x $100 a month = 1.5 million a month, every month. Suppose that the three day conference in Vale costs 15,000 per person – is it good for the pharmaceutical companies to spend this money if it makes doctors aware of their drug? Is it okay for doctors to go to such conferences, especially when the information at the conferences seems unbiased?

There is never a sales pitch in this process and no one hides any information about the drugs. The pharmaceutical companies really only want to give good honest information about their drugs, and if they ever tried to persuade doctors of anything then the doctors are smart enough to detect explicit attempts to corrupt them. Cut can corruption be inherent in the very act of delivering non-biased information? If the exact same information were delivered at a conference in a boring uncomfortable location, would that still be a corrupting influence? Is there any difference in the route by means of which the information is delivered?

I can understand why doctors need comfort but I also think there is something inappropriate about pharmaceutical companies delivering information in this way. I think the ideal situation would be that doctors still get the luxury conference experience, but that somehow the sponsor of the conference to be completely unknown and hidden. I have never heard of a pharmaceutical company sponsoring a conference in that way; they instinctively know that they need their name known as sponsor of the conference. Again, there is something about accepting a gift from another person which endears the receiver to the giver.

Dr. Santa is very conscious of conflict of interest now and I appreciated the insight he could provide as an insider who continues to advocate for consumer interest.

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